Shingles

Through education, nurses can help lessen patients' pain and suffering.

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Learning Scope #436
1 contact hour
Expires May 30, 2015

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70% or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide the latest information to nurses about shingles. After reading this article, you will be able to:

1. Identify how shingles is manifested and treated.

2. Use the latest evidence-based findings when discussing prevention of shingles.

3. Guide patients to appropriate resources for treatment and prevention.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Shingles is a painful, blistering skin rash caused by the varicella-zoster virus (VZV) - the same virus that causes chickenpox. After an acute episode of chickenpox has subsided, the VZV (sometimes called the chickenpox virus) remains dormant in certain nerves in the body. It can then become active in these nerves years later. Thus, everyone who has ever had chickenpox can develop shingles at some time in their lives.1,2

Nurses can help prevent the pain and disruption to normal daily activities shingles causes. This article provides information nurses need to teach their adult patients about shingles and help these patients make informed decisions about receiving the shingles vaccine.

Manifestation & Treatment

The reason VZV suddenly becomes active is not known. However, shingles is more likely to occur in people who had chickenpox before 1 year of age, people older than 50, those who have compromised immune systems and people on immunosuppressive therapy.1,2

The signs and symptoms of shingles typically are more severe in older people.2,3 The first symptom of shingles is usually pain, tingling or burning on one side of the body. Some people have described shingles pain as the worst pain they have ever experienced.

Next, a rash appears on the skin and usually involves one or two adjacent dermatomes (localized zoster), with the thoracic dermatome being the most common. About 20% of those afflicted develop a rash to adjacent dermatomes on both sides of the body. Although less common, shingles rash can affect three or more dermatomes (disseminated zoster), making it difficult to distinguish from varicella. Disseminated zoster generally occurs only in people with compromised immune systems.1

Most of the time, the rash is followed by small blisters that break open and form small sores that dry, crust over and fall off within three weeks. People with shingles also may experience general malaise with headache, fever and chills; abdominal and joint pain; enlarged lymph nodes; and genital sores.

Adults with shingles can be treated with either oral or IV antiviral medications such as acyclovir, famciclovir and valacyclovir to help reduce pain, prevent complications and shorten the course of the disease. However, as with other viruses, antiviral medications need to be started within 72 hours of the first signs and symptoms of shingles. Strong anti-inflammatory corticosteroids, such as prednisone, can be used to reduce swelling and pain as well. However, these are not effective in all patients. Other medicines used to provide symptom relief include:

• Antihistamines for itching. These can be taken by mouth or applied as a cream to the affected areas.

• Various analgesics are helpful for pain control.

• Various creams containing capsaicin have been reported to reduce the risk of post-herpetic neuralgia (PHN), pain that persists after an acute attack of shingles subsides.

Nurses also can suggest certain comfort measures that may help soothe their patients, such as cool, wet compresses; soothing baths and lotions such as colloidal oatmeal bath or starch baths; and lotions such as calamine lotion. Individuals with eye involvement may need to wear an eye patch to prevent corneal abrasion and other eye damage.

Preventing the spread of VZV is important. Caution people with oozing shingles blisters to stay away from others, particularly pregnant women, those who have compromised or suppressed immune systems, and those who had not had chickenpox or received the chickenpox vaccine. The infectious person also needs to stay away from premature infants born to susceptible mothers as well as infants born at less than 28 weeks gestation or who weigh less than 1,000 grams, regardless of whether the mother had chickenpox or has been vaccinated.

People cannot get shingles from a person who has shingles. However, a patient with shingles who has active lesions caused by herpes zoster can pass VZV to another individual, and if that person has not already had chickenpox or taken the chickenpox vaccine, he or she can develop chickenpox, but not shingles.

Therefore, it is important for nurses to counsel their patients with shingles to keep their skin clean and blisters covered. It is also important to remind them to dispose of or disinfect all contaminated objects. Counsel your patients that the virus spreads when a person has direct contact with the lesions and that the lesions remain infectious until they dry and crust over.1

Shingles usually resolves without complications. However, temporary or permanent weakness or paralysis can occur if VZV infects motor nerves. Additionally, some people may experience PHN - pain caused by damaged nerve fibers. This pain may last for months or years after an acute shingles episode. PHN is more likely to occur in people over age 60.2,3

An 8% capsaicin patch can reduce PHN pain and typically provides relief for up to three months. Nurses need to advise their patients the patch requires special handling and should be applied by a healthcare professional. Some skin preparation also is needed for the one-hour long treatment with a patch.4

Other complications of shingles include:

• Another acute episode of shingles later in life.

• Infection, including bacterial skin infections, encephalitis or sepsis, particularly in people with compromised immune systems.

• Blindness or deafness depending on which nerves were involved in the acute episode.

In severe cases of shingles, particularly severe cases of facial nerve involvement, VZV can spread to areas of the brain or the spinal cord, causing confusion, lethargy, headaches, limb weakness and nerve pain. If this occurs, the patient usually requires hospitalization.

Ramsay Hunt Syndrome

A special presentation and/or complication of shingles is Ramsay Hunt syndrome, which occurs when the VZV attacks facial nerves.5 The symptoms of Ramsay Hunt syndrome differ depending on which facial nerves are involved and may include:

• pain, muscle weakness and rash involving various parts of the face

• painful rash of the eardrum, ear canal, earlobe, tongue and palate on the affected side

• hearing loss on the affected side

• vertigo

• difficulty chewing, grimacing, difficulty with fine movements of the face, facial droop and paralysis of one side of the face

• difficulty closing one eye, inability to move the eye, ptosis (drooping eyelid) and other vision problems

• problems with taste sensation.

People with mild cases of Ramsay Hunt syndrome usually recover completely within three weeks. Those with more severe cases may take longer to recover and these individuals may experience residual damage. Overall, 70% of patients with Ramsay Hunt syndrome make a full recovery if treatment is started within three days. However, if treatment is delayed for more than three days, the chances of complete recovery drop to about 50%.

Prevention

The CDC's Advisory Committee on Immunization Practices recommends adults ages 60 and older who have had chickenpox in the past get the VZV or shingles vaccine to prevent shingles and the pain associated with it.6

Currently, only one varicella-zoster vaccine is available: Zostavax (zoster vaccine live). Research shows Zostavax, a one-time use vaccine, is effective for up to six years and reduces the risk of shingles by about 51% and the risk of PHN by 67%. While the vaccine was most effective in people ages 60-69, it also provided some protection for older age groups.6

The CDC does not currently recommend Zostavax for people ages 50-59. However, the FDA approved the vaccine for this age group.

Nurses need to make sure that their patients know that Zostavax protects them only against shingles and not any other virus. It is also important to stress Zostavax is not used to treat active shingles or PHN.

Many people do not recall if they had chickenpox as a child and wonder whether it would harm them to get the shingles vaccine. The CDC recommends everyone ages 60 and older get the shingles vaccine because about 99% of Americans over age 40 have had chickenpox even though they may not remember having it.6

Many people who have already had an acute episode of shingles wonder if they can be given Zostavax. Nurses can assure them getting the vaccine is not contraindicated and will prevent them from having a future acute episode of shingles. Advise your patients who have already had an episode of shingles to consult their primary care provider if they still have questions about the efficacy of getting vaccinated for shingles.

On the other hand, people should not get the shingles vaccine if they currently have a shingles rash. They should be advised to wait to be vaccinated until after the rash has completely disappeared.

Zostavax is not for everyone, and the following people should not be given it:6

• anyone who has ever had a life-threatening or severe allergic reaction to gelatin, neomycin or any other component of shingles vaccine

• anyone who has a weakened immune system or on immunosuppressive therapy

• anyone currently undergoing cancer treatment such as radiation or chemotherapy, or who has active cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma

• women who are or might be pregnant

The most common side effects of Zostavax are redness, soreness, swelling or itching at the injection site as well as headache. Nurses should counsel patients that some people may develop a chickenpox-like rash near the injection site. It is recommended this rash be covered until it disappears.

It also is important to share with patients that no evidence exists of a person getting chickenpox from someone who has received the shingles vaccine. Thus, it is safe to be around infants and young children, pregnant women or people with weakened immune systems after receiving Zostavax. Many people are concerned about additives to vaccines, particularly thimerosal, a preservative containing mercury. Zostavax does not contain thimerosal.6

Obtaining & Paying for the Vaccine

Zostavax is available from primary care providers and from pharmacists in states that permit them to administer vaccines. Many large chain pharmacies have websites that describe what vaccines they have available. Nurses can locate healthcare facilities or pharmacies that offer the vaccine by visiting www.zostavax.com and entering a ZIP code.

Zostavax usually costs from $79-$89. There are a variety of ways to cover the expense.6

• Medicare Part D covers Zostavax; however, there may be some cost-sharing. Medicare Part B does not cover Zostavax.

• Coverage under Medicaid varies; contact the insurer to find out.

• Most private health insurance plans cover the vaccine for people ages 60 and older, while some plans cover the vaccine for people ages 50-59.

A special program set up by Merck, the company that manufactures Zostavax, helps cover the costs of all vaccines they make.7 The Merck Vaccine Patient Assistance Program is a private and confidential program that provides vaccines, including Zostavax, free of charge to eligible adults. It is a fairly straightforward process to participate in the program. Some paperwork needs to be filled out by the patient and primary care provider and faxed to the program prior to the administration of the vaccine. To be eligible, the following three conditions must be met:

• The person needs to be a resident of the U.S. and at least 19 years old.

• The person has no health insurance coverage.

• The person meets certain income limitations. Currently, these are: less than $44,680 for individuals; less than $60,520 for couples; and less than $92,200 for a family of four. Different income limits apply for Alaska, Hawaii, Puerto Rico, U.S. Virgin Islands and Guam. Nurses in these areas can contact the Merck Vaccine Patient Assistance Program directly for more information.

Because of special circumstances or financial or medical hardship, some individuals may be eligible for participation in the program even if the above three conditions are not met. It is best to contact Merck directly to see if the patient might qualify for an exemption.

A Key Role

Many aspects of our patients' health are impacted by our interventions. Whether we are answering questions about the differences between chickenpox and shingles, describing the consequences of getting shingles, or helping a patient decide whether or not to get the shingles vaccine, nurses play key roles in helping patients make healthcare decision that impact their lives. When it comes to shingles, nurses can provide the necessary information and guidance to help prevent the pain and suffering that shingles causes.

References
1. CDC. Shingles. http://www.cdc.gov/shingles/index.html
2. Vorvick LJ, Vyas JM, Zieve D. Shingles. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001861
3. Cohen J. Varicella-Zoster virus (chickenpox, shingles). In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia: Saunders Elsevier; 2011: Chapter 383.
4. Goswami A. Patient education and self-advocacy: questions and responses on pain management. Capsaicin. http://www.ucdmc.ucdavis.edu/pain/Pain%20Resources/Capsaicin_Goswami.pdf
5. Jasmin L, Zieve D. Ramsay Hunt syndrome. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002613
6. CDC. Vaccines and preventable diseases: shingles vaccination: what you need to know. http://www.cdc.gov/vaccines/vpd-vac/shingles/vacc-need-know.htm
7. Merck. Merck Vaccine Patient Assistance Program. http://www.merck.com/merckhelps/vaccines/home.html

Joan M. Lorenz is a clinical specialist in psychiatric mental health nursing for adults. Throughout her career, she has held a variety of clinical positions, including patient safety manager, nurse manager, staff development educator and patient education coordinator. She currently provides consultation and workshops on a number of issues designed to empower work teams to make changes needed to put more joy in their work environments.




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